The majority of healthcare providers do not routinely screen, counsel, or refer patients who use or abuse tobacco, alcohol, or illicit drugs. This has far-reaching consequences, including excess morbidity, premature mortality, and inflated healthcare costs arising from unidentified and untreated substance abuse. To address this problem, Polaris Health Directions (Small Business Concern) and RWJMS (Research Institute) partnered for the development of the Dynamic Assessment and Referral System for Substance Abuse (DARSSA). All Phase 1 aims were achieved. The DARSSA's most important innovations include (1) providing a brief assessment that, in addition to substance abuse, covers a broad range of important, frequently co-occurring psychosocial problems (e.g., depression, domestic violence);(2) generation of separate reports tailored to the specific needs of the respective end-users;(3) highly tailored referrals for all three major drug classes -- tobacco, alcohol, and other drugs;and (4) an ability to transmit dynamic (electronic) referrals to a program matched to key patient characteristics. Key Phase 2 innovations include the addition of (5) an electronic health records interface, (6) a semi-automated referral provider registration, (7) expected treatment response profiles to assist in clinical decision making, (8) auditory item presentation, and (9) an evaluation of 2 different implementation models as a universal assessment and as a clinically indicated tool. The public health impact of such a program can be formidable if applied using system-based approaches. The Phase 2 Specific Aims are to (1) modify the DARSSA based on Phase 1 results and the initial review group's recommendations;(2) test the revised DARSSA to confirm the enhanced system's fidelity;and (3) evaluate the effectiveness the final DARSSA for improving substance detection, counseling, referral, treatment engagement, and abstinence. The Evaluation Study will use a reversal (A-B-A) design and will study integrating the DARSSA into routine clinical care in three different emergency departments (EDs). The primary difference between the baseline (A) and intervention (B) phases is that, during the intervention phases, the subjects will have their DARSSA reports printed and will be given the option of receiving the dynamic referral, while during the baseline phases the subjects will undergo the assessment only. The number of assessments and interactions with research staff will remain equal between the two conditions. We anticipate enrolling 810 risky substance users in the treatment-as-usual (control) condition and 486 in the DARSSA (intervention) condition. All risky substance users will be followed for 3-months. The DARSSA's commercial potential is considerable, with a favorable return on investment from: (1) increased compliance with the Joint Commission (formerly JCAHO) and other regulatory mandates, (2) increased reimbursement from improved documentation, (3) enhanced revenue generation through increased reimbursable counseling (e.g., Medicare), and (4) cost savings from reduced substance abuse. PUBLIC HEALTH RELEVANCE: The Dynamic Assessment and Referral for System for Substance Abuse (DARSSA) is an innovative product with potential to improve public health through identifying and linking patients who abuse tobacco, alcohol, or other drugs with treatment. The intervention is being studied in the emergency department (ED) setting to demonstrate its feasibility and utility in the most logistically challenging medical setting, but it is relevant for a broad array of healthcare settings ranging from outpatient offices to inpatient wards. Our study challenges existing paradigms that rely exclusively upon human-based screening, brief intervention, and referral to treatment (SBIRT) interventions for substance use, which are costly and, therefore, not commonly adopted in clinical settings.